Denials Management Specialist

At Houston Methodist, the Denials Management Specialist (DMS) position is responsible for reviewing, coordinating, and monitoring the clinical denial management and appeals process in a collaborative environment with Central Business Office (CBO) management and clinical partners at the various Houston Methodist facilities. This position combines clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided, including but not limited to reviewing denials for level of care, medical necessity, Diagnosis Related Group (DRG) recoupments/downgrades, denials for no authorization, and denials related to an audit review. The DMS position collaborates with physicians, case managers, revenue cycle personnel and payors to successfully appeal technical and clinical denials. Additionally, this position collaborates with management to develop meaningful appeal strategies to include reference material for staff, letter templates, education regarding regulatory standards as relates to denials, training for staff and functions as clinical subject matter expert related to clinical and technical appeals. The DMS position facilitates accurate reimbursement through appeal writing and provides feedback for process and workflow opportunities to both operational and clinical owners serving as an integral member of the system Denials Management team at each facility within Houston Methodist.

FLSA STATUS
Exempt

QUALIFICATIONS

EDUCATION

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
• Bachelor of Science preferred

EXPERIENCE

• Seven years clinical nursing/patient care experience with five years in utilization review with clinical decision tools such as Interqual, Millimann, etc, case management or equivalent revenue cycle clinical role, including past experience in initiating and facilitating physician peer to peer review, medical/clinical denials and appeals
• Must have experience with prior authorization process for all providers, ordering and rendering.

LICENSES AND CERTIFICATIONS
Required

• LVN - Licensed Vocational Nurse - State Licensure - Texas Department of Licensing and Regulation_PSV license in the state Texas

Preferred

• CPHM - Certified Professional in Healthcare Management (McKesson) and
• CCM - Certified Case Manager (CCMC) and
• ACM - Accredited Case Manager (NBCM,ACMA) or equivalent

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Extensive knowledge of clinical symptomology and related treatment and hospital utilization management
• Knowledge of current reimbursement models: commercial, managed care, government and the technical writing ability to develop and formulate appeal letters and reports
• Ability to communicate both verbally and in writing to a varied of audience including all levels of personnel, physicians, clinical staff, management, and revenue cycle staff
• Motivated and can act independently with minimal supervision
• Excellent listening skills
• Knowledge of medical and insurance terminology and medical record coding (ICD10, CPT/HPCPCS, etc.)
• Advanced proficiency in word processing (MS Word) and proficient in basic spreadsheet applications (Excel)
• Knowledge of electronic health record system
• Demonstrated ability to interact effectively with interprofessional teams, including physicians, and other professionals both internal and external to Houston Methodist
• Maintains knowledge of Federal, State, and local billing regulations and partners with managed care contracting
• Maintains knowledge of ADT, registration and pre-admit/admit workflow processes.
• Maintains knowledge of contracts, billing/follow up procedures
• Demonstrates strong knowledge of commercial insurance and governmental programs, state and federal regulations and billing processes, managed care contracts and coordination of benefits related to coverage, clinical appeals and denials to include knowledge of CPT and ICD codes and familiarity with Local Coverage Determination (LCD)/ National Coverage Determination (NCD)
• Competence in writing clinical appeals for medical necessity compliance or level of care for government and nongovernmental payors
• Ability to develop an appeal strategy and facilitate clinical appeals to ensure recovery

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• Trains staff in denials and appeals process, denial management, and medical coverage guidelines. Serves as an educational liaison to clinical, revenue cycle, central business office and facility operational staff, as needed, on payor denials, denial reason and trending, interpretation of payor manuals, medical policies and local/national coverage determinations or other regulatory requirements related to denials and appeals. Contributes to improving department employee satisfaction/engagement.
• Assists in mitigating avoidable denials by communicating directly with physicians, case management staff, clinical service areas, department staff, CBO partners, and vendors to convey payor requirements and reasons for denials. Accurately, timely and consistently communicates by telephone, in meetings, email, and other written correspondence in a clear, effective manner, to resolve claim delays or denials. Conducts value-added conversations with the goal to maximize efficiency and avoid denials and write-offs. Feedback should be proactive and continuously cultivated.
• Actively participates in payor meetings, including meetings with government reviewers to assist in mitigating denials. Partners with local denial management and/or audit review work groups, impacting them by identifying why services are denied, root causes, and applicable payor medical policies, Local Coverage Determination (LCD)/National Coverage Determination (NCD), etc. to develop successful appeal strategies

SERVICE ESSENTIAL FUNCTIONS

• Provides clinical support to department staff and management for data gathering and review. Assists in resolution of inpatient and/or outpatient denials, as well as other tasks related to reimbursement or denial mitigation. Participates in regular meetings with Case Management, Revenue Cycle Denial Meetings, department staff meetings, and facility clinical leaders to share information regarding denial trends, audit reviews, and opportunities for reduced denials. Provides Management with feedback on Patient Access Services, Health Information Management, and Utilization Review and other issues, as appropriate, as related to denials.
• Proactively monitors Center for Medicare and Medicaid Services (Medicare) (CMS) or other applicable regulatory sources, managed care and payor communications for updates/alerts/releases related to authorization requirements and/or denial management and functions as a support and educational resource to appeal staff, clinical operations, and management.
• Partners with management to create applicable tools, resources, letter templates, etc., to support appeal staff to include reviewing letters for appropriateness of appeal position and clinical accuracy. Provides recommendations and assists in resolving payor issues related to reimbursement at risk and the development of strategies to avoid denials.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Analyzes data from various sources (medical records, claims data, Utilization Review Management (UM) criteria such as InterQual or Milliman, payor medical policies, regulatory requirements, etc.); determines causes for denials of payment and partners with management to implement strategies to prevent future denials. Integrates the payor medical policies, case specific medical documentation, regulatory requirements, and claims information into a concise appeal letter or strategy, including appropriate medical records submission as needed. Partners with IT and Billing Managers to review software updates to ensure accurate medical necessity data and compliance with government updates which includes participating in the testing phases to ensure claims are evaluated for medical necessity appropriately.
• Responsible for gathering and maintaining accurate statistics on denials, payment recovery, and changes in payor requirements. Provides information to management and senior leadership as needed. Provides timely reports of results of medical necessity denial analysis and reviews to manager as well as key customers at the local entity.
• Performs timely review of medical records and remittances for denials to determine root cause and appropriateness. Assists in the development of corrective action plans in the local denial work group which may include partnering with physicians, clinical service areas, patient access, medical records, other operational leaders, etc.

FINANCE ESSENTIAL FUNCTIONS

• Partners with department leadership, patient access leadership, Case Management, Health Information Management, and facility clinical operations to reduce denials. Reviews denials and/or inquiries referred from other departments and assists in identifying root causes such as medical necessity, contractual, investigational/experimental, plan exclusions, level of care discrepancy, under payments, exhaustion of benefits, and helps determine feasibility of appeal success along with best appeal strategy.
• Works with department management and appeal staff to ensure denial trending data is accurate and that all metrics are reported appropriately including specific Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), denial reasons, trended Diagnosis Related Group (DRG) recoupments, and appeals. Monitors recovery of payments, monitors trends to identify corrective measures needed to prevent denials.
• Negotiates, as needed, with payors for a lower level of care for days of service not meeting higher level of care criteria where supported by Case Management and where payor contracts allow.
• Analyzes denials to identify process or workflow improvements and partners with management to implement as needed including providing feedback to patient access services and coding staff, physicians, and operational and facility leaders. Identifies internal system activities that may be causing denials and works with stake holders to mitigate avoidable denials.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Collaborates with third party appeal vendors to identify denial and recovery trends and partners with department management to strategically improve processes.
• Identifies and assumes responsibility of own learning needs, consults with healthcare team experts and seeks continuing education opportunities to meet those needs. Completes and updates the individual development plan (IDP) on an on-going basis. Ensures own career discussions occur with appropriate management.

SUPPLEMENTAL REQUIREMENTS
WORK ATTIRE

• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area No

QUALIFICATIONS

EDUCATION

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
• Bachelor of Science preferred

EXPERIENCE

• Seven years clinical nursing/patient care experience with five years in utilization review with clinical decision tools such as Interqual, Millimann, etc, case management or equivalent revenue cycle clinical role, including past experience in initiating and facilitating physician peer to peer review, medical/clinical denials and appeals
• Must have experience with prior authorization process for all providers, ordering and rendering.

LICENSES AND CERTIFICATIONS
Required

• LVN - Licensed Vocational Nurse - State Licensure - Texas Department of Licensing and Regulation_PSV license in the state Texas

Preferred

• CPHM - Certified Professional in Healthcare Management (McKesson) and
• CCM - Certified Case Manager (CCMC) and
• ACM - Accredited Case Manager (NBCM,ACMA) or equivalent